In the first installment of the Closer Look at RCM series, we have enumerated the four categories of solutions under it, namely: Front-End, Transaction Processing, Back-End and Support. As any process under healthcare management services, Front-End and Transaction Processing is no different when requiring a high attention to detail. These are the two main categories of pharmaceutical revenue cycle management solutions which are responsible for patient information gathering and payments processing.

Front-End is the primary stage of the cycle and this is where information such as name, status, age, and address are gathered. However, the more important and highly relevant information that should also be obtained in this stage are the patient’s insurance information and the procedure that needs to be performed. After the basic facts are verified and put into place, it is important to determine whether the patient is entitled and eligible to undergo the procedure that s/he requires. To determine if the eligibility request is valid, the insurance company should provide an updated set of guidelines to the medical billing partner. This can make room for a faster and seamless processing. Because a lot of claims are being denied due to incorrect insurance coverage information, the medical eligibility verification is as important as the other processes. Having determined that the patient can go through the procedure, the appointment with the physician is scheduled. With regard to payment, it is essential and recommended for the medical billing company to obtain the patient’s financial status and if necessary, his/her financial history. There are instances when the insurance provider does not entirely cover the procedure fees, and it is only fair to the patient to get an estimate of the out-of-pocket deposits that he/she must do. This can be helpful in arranging the payment methods and managing the deductibles, if there’s any.

The medical billers also need to prepare the medical encounters and create a clinical documentation for it. Since medical encounters contain the patient’s medical history, it is expected that the staff has access to record and/or review a patient’s file. The staff are granted access to sensitive data, thus it is expected that they maintain confidentiality with all information provided to them. It is in these medical encounters where the codes are added and recorded. It may seem simple at first but in actuality, it is complex. Each procedure or test to be done has a corresponding code and just imagine the variation in medical procedures available today; also, ICD-10 is just around the corner and will be implemented in the following year, which means another set of codes to review and implement.

Transaction Processing, on the other hand, is the stage where medical billing and medical practice meet. This could be even considered as the core of the healthcare revenue cycle management. It is in this particular stage where charge entry, claims scrubbing and pre-adjudication happens. These steps are necessary so medical billing companies can enter the medical procedure codes or values into the system, check the supporting data for each medical claim, as well as check the coding accuracy. This is where medical billing companies determine the inaccuracies in the initial stage of revenue cycle management.

Inbound processing happens in this stage, where bank deposits happen and payments are posted.

At a glance, Revenue Cycle Management seems very simple. But getting an in-depth understanding of the cycle is impossible to be achieved in only one blog article. It is a complex and detailed process, hence the term ‘cycle’, where a lot of coordination happens between the medical entity and the medical billing company. Having an understanding of the cycle will enlighten you as to why medical billing companies seek the assistance of a certified healthcare outsourcing company. An outsourcing partner can assist in medical billing processes, such as Front-End and Transaction Processing without undermining the entire cycle.

Come back for the third and last installment of the Closer Look at RCM series. Meanwhile, you might enjoy reading the other healthcare blog articles we have published.

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